2018 VACATION BIBLE SCHOOL REGISTRATION FORM

June 25-29, 2018 from 9:00 am until 12:00 pm (noon)

Child's Name *
First Name
Middle
Last Name
Parent / Guardian's Name *
First Name
Middle
Last Name
Address *
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Home Phone #
Work Phone #
Cell Phone #*
Email
Child's Age Information
Birthday (MM/DD/YYYY)*
How old is your child?*
Last Grade Completed In School*
Medical Information
Medical Information that we need to know. (Please include food allergies and medications)
Emergency Contacts: (other than listed above)
Emergency Contact 1 Name *
First Name
Middle
Last Name
Emergency Contact 1 Phone Number*
Emergency Contact 2 Name
First Name
Middle
Last Name
Emergency Contact 2 Phone Number
Dismissal information: Name(s) of person(s) other than parent or guardian listed above that may pick up.
Pick up person 1
First Name
Middle
Last Name
Pick up person 2
First Name
Middle
Last Name
Pick up person 3
First Name
Middle
Last Name
Is your family currently attending a church?
In the event that the contacts listed above cannot be reached in an emergency, I hereby give permission to the physician selected by TLBC’s staff to secure proper treatment for the child named above. I/We release and discharge Thalia Lynn Baptist Church from any legal or medical claims, demands, actions or cause of action, past, present, or future arising out of any injury while participating.
Do you agree to the above statement?*